News Center

Posted on Apr 16, 2015

There is no shortage of unsettling news about highly infectious diseases.
We’ve been alerted to Ebola ravaging Africa, a worse-than-normal
flu season with only a moderately effective vaccine and a measles outbreak.
But how do we decipher what’s newsworthy and what’s an actual threat?

Wading through the noise to figure out what hospitals are actually seeing
can be a tall order. We asked two Torrance Memorial Medical Center doctors
on the front lines of infectious disease to explain what they deal with
on a daily basis.

MEASLES

We are in the midst of a measles outbreak, which has affected more than
140 people—many who are adults—and is believed to have originated
at Disneyland. Last year was also a record year for measles. According
to the Centers for Disease Control and Prevention (CDC), 2014 had the
highest number of measles cases (644) they have reported in 20 years.

This year’s outbreak is alarming because in just one month the number
has exceeded what is typically seen in many years. Measles is highly contagious
and can spread through the air by coughing and sneezing. While symptoms
may be limited to fever, cough and rash, they can also progress to complications
including pneumonia, ear infections and diarrhea.

The CDC and health departments are urging people to get vaccinated—
the most effective way of preventing the disease. The majority of this
year’s reported cases are among unvaccinated individuals. According
to a statement by Anne Schuchat, the director of the CDC’s National
Center for Immunization and Respiratory Diseases, “This is not a
problem with the measles vaccine not working; this is a problem of the
measles vaccine not being used.”

Adults who are unsure of their immune status can have a titers blood test,
which will show their level of immunity to measles. “Your primary
care physician can arrange for a simple blood test to check your immune
status,” says Eric Nakkim, MD, who has worked in the ER for 18 years.
“People born before 1957 or those who have documentation of at least
two separate MMR (measles/mumps/rubella) shots are very likely to already
be immune. If you think you might have measles, call your doctor for advice
on what to do. If you aren’t having any serious symptoms like shortness
of breath, it’s best to not expose others and just stay home.”

According to Eric Milefchik, MD, chairman of the Infection Control Department
at Torrance Memorial, if you believe you have been exposed to someone
with measles, you should consult your physician, as there may be a strategy
to prevent infection.

“In general, non-immunized persons can prevent measles if vaccinated
with MMR within three days of an exposure. A much more difficult and expensive
injection or infusion of immunoglobulin is given within six days of exposure
for very high-risk patients, such as infants less than 1 year old or immunosuppressed
individuals. Adults without known exposure to measles and who have no
history of vaccination or blood testing showing immunity can consider
receiving MMR vaccination in consultation with their physician.”

Dr. Milefchik adds that vaccination is not recommended for adults born
before 1957 due to the high incidence of measles in this group. Those
vaccinated from 1963 to 1967 may not have lasting immunity and should
get a blood test. Those vaccinated after 1967, especially if they received
two doses, should be reliably immune.

All children should have two doses of the MMR vaccination—the first
at 12 months of age and the second at least 28 days later but usually
administered before school age. “Parents with children who have
declined vaccination should strongly reconsider their reasons for such—not
only for their own health but for that of others,” says Dr. Milefchik.
“We all benefit when vaccination levels for longrunning and safe
vaccines such as the MMR remain high (over 92% for children). Outbreaks
such as we are seeing now with potential for suffering, permanent disability
from encephalitis or death are then easily eliminated.”

INFLUENZA

Of particular concern is this year’s flu. “This is the worst
influenza season we’ve seen in a long time,” notes Dr. Milefchik.
“We’re seeing a lot of cases.”

According to flu.gov, a normal mutation in one of the active strains means
that this year’s vaccine may be less effective than anticipated,
and as a result even vaccinated people are getting the disease. The vaccine
is still effective in preventing two other flu strains, and people who
are vaccinated may experience a milder illness than those who are unvaccinated.

Because of the severity, Torrance Memorial has increased screening of patients
and is taking more precautionary measures, similar to those that were
taken during the 2009 outbreak of the H1N1 swine flu outbreak. Right now,
visitors to the hospital are limited. Kids under 14 years of age are not
allowed to visit due to risk of spreading the disease.

“Children are very effective spreaders of the flu,” notes Dr.
Milefchik. As any parent of a youngster recognizes, they are not exactly
experts at covering a cough or washing hands after touching a runny nose.

In addition, kids usually carry higher viral loads than adults do because
they don’t have fully developed immune systems. “What we’re
trying to do is protect very vulnerable patients. We want to prevent already
sick people from getting this influenza,” says Dr. Milefchik.

MRSA

The flu is seasonal, but many diseases seen in the hospital are ongoing
problems that affect populations worldwide. Multi-drug resistant pathogens
are a result of overuse, and inappropriately prescribed antibiotics present
a challenge in a health care setting where immunecompromised patients
are particularly vulnerable to a new infection.

One particular threat is methicillin-resistant
Staphylococcus aureus, or MRSA (pronounced “mersa”), a type of staph bacteria that
is resistant to several antibiotics. Normally staph causes skin and other
types of infection. However in hospitals and nursing homes, MRSA infections
can lead to pneumonia and surgical-site and bloodstream infections. This
and other antibioticresistant bacteria can be extremely hard to treat.

“Around 30% of people carry staph around on their skin—in their
nasal mucosa, armpits and throat, for example,” says Dr. Milefchik.
Around 1% of people carry MRSA; in both cases, they may carry it without
getting sick.

However, in certain cases it can lead to infection. Dr. Milefchik notes
that it used to be that staph would cause problems if someone had a wound
or laceration, but new strains can cause people to develop boils without
a break in the skin.

Even when antibiotics are used appropriately, they can still lead to problems.
“The antibiotic era has ushered in new infections,” says Dr.
Milefchik.

One of these is Clostridium difficile, or C. diff. This infection comes
about when people are on antibiotics to treat an infection. Because broadspectrum
antibiotics kill normal gut bacteria, people are more susceptible to harmful
ones, like C. diff, which can be spread in hospitals and causes severe diarrhea.

EBOLA

An infectious disease is often first identified in the emergency room,
where a specially trained nurse does an assessment. Although Ebola may
have grabbed the headlines due to its severity and contagiousness, it
is very rare in the U.S.— but that doesn’t mean the hospital
isn’t staying vigilant in case there is an emergency.

“For possible Ebola, Torrance Memorial has assembled a team of nurses,
physicians and respiratory therapists from the intensive care unit and
emergency department.

We are trained and drilled in personal protection and treatment protocols
based on the most stringent national guidelines,” says Dr. Nakkim.
“But in the ER we are much more likely to see various respiratory
infections like bronchitis, influenza and pneumonia. Most infectious illnesses
are relatively straightforward to diagnose when the patient has a full-blown
case.”

The challenge in the ER is that when an infection is just becoming established,
the signs and symptoms in the patient may be subtle. An elderly patient
with early pneumonia may only complain of being weak or tired, as opposed
to the classic fever/chills, cough and shortness of breath.

Screening involves determining chief complaints and related symptoms, checking
for fever and vital signs, and asking about pertinent travel history.
“This information is coupled with local and national disease patterns
to help determine where and how the patient should be treated,”
says Dr. Nakkim.

PREVENTING THE SPREAD OF INFECTIONS

Stopping the spread of pathogens like MRSA, C. diff and other difficult-to-treat
organisms is a high priority at Torrance Memorial.

Since the goal is rapidly assessing and treating a patient while also protecting
other patients and health care workers, clinicians use isolation rooms
for patients with a suspected highly virulent illness. In the new Lundquist
Tower, all patient rooms are private, making isolation easier, says Dr.
Milefchik.

In addition, Torrance Memorial has increased the screening of patients
for MRSA. If a patient does have MRSA, health care workers do barrier
isolation—wearing gowns, gloves and masks or face shields. Patients
are also bathed in chlorohexidine, an antiseptic antibacterial that can
help reduce transmissibility.

For suspected flu patients, health care workers wear face masks (also called
“droplet isolation”), which helps prevent the spread of the
virus. Torrance Memorial is also taking an active stance in preventing
these infectious diseases from arising in the first place and improving
clinical treatment of them.

“Some of the more difficult infectious diseases to treat are due
to the rise of multi-drug resistant pathogens. Antibiotics are way overprescribed
in the U.S.,” says Dr. Nakkim. “Examples of this would be
treating a cold virus with antibiotics, treating a urinary tract infection
in a patient with no symptoms or prescribing broad-spectrum antibiotics
for a skin abscess instead of simply draining it. Torrance Memorial’s
Antibiotic Stewardship Program helps physicians prescribe the right antibiotic
in the right setting.”

Using evidence-based protocols creates a standardized approach to treating
infectious disease, resulting in clearer decision-making for the physician
and also better care for the patients, says Dr. Nakkim. “This also
protects everyone else in our community by doing our part to limit drug-resistant
bacteria.”

In addition, Dr. Milefchik notes they are doing research on the best way
to treat patients with MRSA. Currently they are looking at the effectiveness
of chlorohexidine bathing versus isolation.

POTENTIAL PATHOGENS

Torrance Memorial stays alert to infections arising in the community. West
Nile Virus, which mosquitoes transmit to humans, was a problem in 2013.
Although there haven’t been many cases this year, it is now endemic
to mosquitoes in the area. Other infections on the radar include Enterovirus
68, which is currently a problem mainly on the East Coast and in the Midwest
and can cause severe respiratory illness.

Preparedness and training have helped Torrance Memorial stay on the forefront
of problematic pathogens. Dr. Nakkim notes, “When patients, health
care providers and hospital leaders work together as a team, those germs
don’t have a chance!”